Picc line resistance and bleeding

[katfish67lpn]

I am an IV certified LPN with 26 years of experience. I am working on a skilled unit in a SNF. I had a pt. with a PICC line last night. When I went to flush the PICC there was a lot of resistance. I did the usual maneuvers, reposition the arm, had the pt turn his head, cough etc. These methods were not successful so I went and asked the RN to assist me in troubleshooting. What she did was push and pulled very hard multiple times and finally she was able to aspirate back some blood and then she proceeded to push the flush through using quite a bit of force. I ran the antibiotic in and flushed without difficulty after the Abo (50cc's over 30 mins). At that time the PICC line drsg was clean without s/sx of infection and no bleeding. I went in 12 hours later to infuse the next scheduled Abo. and this time there was fresh blood from the PICC insertion site and running down the tubing. This bleeding was new and again the line would not flush. I did not force it and left it for the oncoming RN because it was 6:45am by this time and dayshift was taking over anyway. I just am not comfortable with the push/pull force method and I just wondered how common is it to use this method to deal with resistance and is it really safe. I was concerned because the bleeding was obviously new and I just don't want to possibly harm someone by using that "method".

[concordance]

I think I would be surprised if the two were (the sluggish flush and the bleeding) were related because the tip is so far from the insertion site. The PICC has probably grown a fibrin tail (like a little flap of a clot) on the end which is causing some of your flushing/aspirating difficulties. (It's common for anything foreign in the body to attract "junk.") I'd ask for an order for alteplase or similar to declot the line.

As for the bleeding, it could be related to moving the arm, fiddling with the line, or absolutely nothing you did. In cases of bleeding or oozing: hold pressure until it stops and change the dressing.

[Asystole RN]

There are many potential causes for a sluggish PICC.

One of the potential issues is a malpositioned catheter, where the catheter will move out of the ideal position within the superior vena cava. Sometimes the catheter will loop, get jammed against a vessel wall, go contralaterally into the brachiocephalic/subclavian vessel, or positon into the internal jugular etc. Having the patient turn their head and cough (while attempting to flush and having the patient sit upright simulaneously) is a technique to drop the catheter back into correct positioning. If a malposition is suspected the golden standard of treatment is to check placement with a chest radiograph. This complication is however is generally not the most common of complications.

Thrombus formation is about the most common of complications associated with PICCs, they can form intralumenally or extralumenally, as a tail or a sheath. Cathflo Activase (alteplase) is the drug of choice when attempting to declot a PICC, most facilities require a RN to administer the medication however. More information on them here Mechanism of Action — Cathflo® Activase® (alteplase)

Occlusions can form from other things though too like lipids from TPN or drug precipitates which all have their own drugs to dissolve the occlusion. These forms of occlusions are rare however.

Another, and often overlooked, cause of occlusion is actual tubing kinking. This often happens at the insertion site and is relatively common if the clinician is coiling the catheter. This is why some say that if there is an occlusion that one should change the dressing first and then reevaluate.

Forcefully aspirating and flushing are techniques to physically dislodge the occlusion. I highly discourage this practice, if you are successful and dislodge whatever is causing the clot there is a good change it will just get swept up into the lungs. Most likely there will be no issue, the body is dealing with clots all the time BUT why take the chance and put a greater burden on the patient's lungs? A PE is not something to risk. Not to mention that forcefully flushing the catheter may also pose a physical risk to the actual integrity of the catheter.

The site bleeding is likely not related to the occlusion. Being a SNF, if the patient undergoes any kind of physical therapy the movement and exercise could be a cause. Some site bleeding is considered normal, using a absorptive anti-microbial at the site like a Biopatch or the Tegaderm CHG dressing could help at least keep the drainage contained.

Asystole RN, BSN, CRNI, VA-BC

Vascular Access & Infusion Therapy Specialist

[IVRUS, BSN, RN]

Great Post Asystole... Couldn't have said it better myself.

[katfish67lpn]

Thank you for your reply. I didn't think the bleeding was due to the occlusion however, it was new and in addition to the resistance I thought it was better to be safe and wait and not try to deal with it as the only nurse in the building on night shift. Also as I said I have seen other nurses (including the nurse that flushed the PICC before the Abo. I hung) push/pull and forcefully flush the line, which is something I won't do. I may gently push or attempt to aspirate the line but to forcefully do either I just don't feel comfortable doing. I just wondered if that was really acceptable and I was just being overly cautious or if it can be really harmful and it should really never be done? Im pretty sure I know the answer which is it really shouldn't be done but I just wanted to pick the brains on Allnurse's. :) The thing about the bleeding was he had been sleeping throughout the night and as I said I had infused the prior dose of Abo. and the site had no bleeding, so this being new and with the resistance (I know not related) I (as I said) wanted more than just myself to deal with it. We all have different experiences and one nurse may have a trick or two that I haven't seen before so I wanted to use my other nurse resources when they came in which would be within minutes. Thank you again for all the great information. ")